- At least 5 attacks lasting 4-72 hours

- Not attributed to anything else

- N/V or photophobia with the HA

- Headache with at least 2 of the following:  Unilateral location, pulsating, moderate or severe pain, avoidance of athletic activity

- neuro exam is not normal

- first migraine after 40 years of age

- freq. or inten. increases

- sx of migraine attacks change

- new psychiatric changes occur

- duration of less than 30-60 minutes

- numbness, tingling

- visual hallucinations or loss of vision

- Premonitory phase

- Aura

- Migraine phase

- Migraine resolution

- External events

- Internal events

- Premonitory sx

- Vasodilation of blood vessels

- Dysfunction of neural pathways

- Aura is cortical spreading depression

- Trigeminal nerve leads to long lasting inflammatory changes

- Calcitonin is released after trigeminal nerve activation

- Pain free at 2 hours

- Reduction of sx from moderate/severe to mild in 2 hours or less

- Consistent efficacy in 2 of 3 attacks

- Relief for 2 hours w/o drug

Proven statistical and clinical benefit from at least 2 double blind placebo controlled studies, plus clinical impression of effect.

- DAT PI BAN

- DHE in various forms

- ASA po

- Triptans

- Prochlorperazine

- Ibuprofen

- Butorphanol

- APAP/ASA/Caffeine

- Naproxen

Moderate statistical or clinical benefit.  At least 1 trial

- KAMP, BIB, MM

- Ketorlac

- APAP/Codeine

- Metoclopramide

- Prochlorperazine

- Butalbital/ASA/Caffeine/Codeine

- Isometheptene compounds

- Butorphenol

- Meperidine

Statistically but not proven clinically or clinically but not proven statistically

- BEEM

- Butalbital/ASA/Caffeine

- Ergotamine

- Ergotamine/Caffeine

- Metoclopramide

BAIN KM (Bain kills many)

- Butorphanol

- ASA

- Ibuprofen

- Naproxen

- Ketorlac (stadol)

- Meperidine (demerol)

Generic:  Isometheptene/APAP/Dichloralphenazone

- 2 capsules, repeat every 1 hour, no more than 5/12 hours 20/month

- CNS depression is an adverse event

- Vasoconstricts, so think of CI

- Caffeine helps absorption of APAP and ASA

- Mild to moderate migraines

- Dose goes 250, 250, 65

- Dose = 2 caplets

- Group 1

- Group 2 with caffeine and group 3 with codeine

- No evidence in migraines, only chronic tension headaches

- MDD = 6 tablets

- Dosage goes 325, 50, 40mg

- Schedule 3

- Rescue med if primary treatment fails

- Codeine 30 or 60, APAP 300 or 600

- q4h, don't exceed 360mg codeine/day

- Group 2

- Codeine side effects

- For acute migraine treatment

- Acute treatment of migraines

- Group 2

- Antipsychotic that increases Dopamine, Serotonin, and alpha adrenergic activation

- decrease bp, drowsiness

- IV if group 1, Group 2 is IM or PR

- The more extreme the method, the lower the dose (IV is 2.5 mg)

- Metoclopramide

- Dopamine and sertonin, increases gastric emptying

- dyskinesia, drowsiness, diarrhea

- CI is history of seizure

- Group 2 IV, Group 3 IM

- Increase serotonin levels

- Inhibit release of inflammatory mediators from trigeminal nerves

- Decrease pain impulses to trigeminal nucleus caudalis

- Decrease calcitonin vasodilation

- FEAR N ZS (Fearin' Zeus?) are the different Triptans

- Anything BP or serotonin related is a CI

- Weird adverse events include eye problems, chest or jaw tightness, photosensitivity, seizures, CV events

- Blackbox warning warning, CV risk

- Naproxen and Triptan

- CI severe liver disease

- CI within 72 hours of CYP3A4 inhibitor

-

- Avoid in renal failure and CYP3A4 inhibitors

- If CrCl < 30 dose is 30 ml/min

- Sulfonamide allergy

- Use caution if brain lesion or epilepsy

- may decrease seizure threshold

- Half life over 25 hours

- Use in caution with liver disease

- no renal adjustment

- CI in severe hepatic disease

- 2.5mg/24h if severe liver disease

- CI if CrCl < 15 ml/min

- If CrCl close to limit, do not exceed 2.5mg/24h

- Maxalt contains phenylalanine

- Use in caution with dialysis

- Propranolol increases Rizatriptan concentration by 70%

- Use in caution with history of seizure

- CI if MAOI within 2 weeks, severe hepatic impairment, vascular or peripheral vascular problems

- Use with caution with dialysis

- Caution with BP patients

- CI in Wolf Parkinson White syndrome?

- Contains phenylalanine

- CI with MAOI

- problems with propranolol

- if mod. to sev. hepatic disease give one half of 2.5 mg dose and monitor BP

- Sumatriptan

- Riza and Eletriptan

- Suma, Almotriptan, Zolmitriptan

- Naratriptan, Frovatriptan

- Most effective Triptans and also associated with highest adverse events

- Nara and Alma cause no more adverse events than placebo

- 2 hour resp.. rate is 45% for nara and frova 65%-70%

- 25% of students do not respond to any triptans

- Triptans are NOT effective when taking during the aura.

- Binds to 5HT-1b1d

- Also interacts 5HT-2

- Interacts with dopaminergic or alpha adrenergic also

Interacts with the following receptors

- 5HT: 1D, 1A, 2A, 2C,

- Noradrenaline Alpha; 2A, 2B, 1

- Dopamine 2L and 3

- Absorption is erratic

- Half life is 2 hours

- Cafergot suppositories/tablets, 2 mg with caffeine.  No more than 5 suppos. a week, no more than 10 tablets a weeks

- N/V, Ab pain, swollen fingers, tremor, leg cramp, burning or tingling at extremities

- Intense vasoconstriction

- may result in gangrene

- More prevalent in people who take more than the MDD

- Hypersensitivy rxns in these pt's also.

- Cat. X prego

- Sepsis, then other HTN related sx

- Bioavailability varies widely

- Not available as tablet

- Group 1

- CI's: Nursing mothers, Prego X, Hemiplegic or Basilar HA, Sepsis following vascular surgery

- Patients should try a medication for 2-3 headaches before d/c class

- If one tripan doesn't work, you can try another one

- DHE 0.5-1mg injection

- Sumatriptan 4-6mg (don't use with a day of DHE)

- Ketorlac 30mg IV or double the dose IM

- Meperidine (Demerol)

- Valproate 500mg IV

- Droperidol 2.5 IV

- Dopamine antagonists (metoclopramide, Prochlorperazine, Chlorpromazine)

- Out of 3 menstrual cycles, have it twice.  Occurs on -2 or +3 menstruation

- Menstrual migraines are sometimes more severe

- The meds are FN ZEN (E is  estradiol patch)

- Usually from withdrawal from a drug

- Treatment should be an opioid or butalbital compound

- QOL is impaired

- 2 or more migraines per month or sx lasting more than 3 days per month

- do not respond to acute treatment

- CI to acute treatments

- Use of abortive treatments more than twice per week